Comparison between ticagrelor versus clopidogrel in long term outcomes of Taiwanese diabetic subjects with acute coronary syndrome undergoing successful revascularization

Abstract

Although previous clinical trials demonstrated that ticagrelor could reduce cardiovascular events and mortality versus clopidogrel in patients with acute coronary syndrome (ACS), the real-world evidence of its clinical impacts on East Asian Diabetic population has rarely been investigated. Between November 2013 and June 2015, 1534 patients were recruited into the Acute Coronary Syndrome-Diabetes Mellitus Registry of the Taiwan Society of Cardiology (TSOC ACS-DM registry). After propensity score matching, a total of 730 patients undergoing successful revascularization and discharged on ticagrelor (N = 365) or clopidogrel (N = 365) were analyzed. The primary and secondary endpoints were all-cause mortality and re-hospitalization, respectively. The all-cause death associated with ticagrelor vs clopidogrel was 3.6% vs 7.4% (adjusted hazard ratio (HR) 0.34 [0.15–0.80]; P = .0138) at 24 months. The re-hospitalization rate at 24 months was 38.9% vs 39.2% (P = .3258). For diabetic patients with ACS, ticagrelor provided better survival benefit than clopidogrel without an increase of re-hospitalization in 24 months after successful percutaneous coronary intervention. This study in real-world circumstance provided valuable complementary data to externally validate platelet inhibition and patient outcomes (PLATO) finding especially in Asian diabetic population.

Cardiovascular Outcomes Observed with Ticagrelor versus Clopidogrel in Type 2 Diabetes Mellitus Patients with Acute Coronary Syndrome: A Meta-analysis

“…Similar to this analysis, a substudy from the PLATelet inhibition and patient Outcomes (PLATO) trial [ 20 ] that assessed ticagrelor versus clopidogrel in patients with ACS and diabetes mellitus showed the former to reduce ischemic events in ACS patients irrespective of diabetic status and glycemic control, without increasing the risk of major bleeding. It should be noted that this PLATO substudy included 4662 participants with T2DM, of which 1036 were on insulin therapy.…”

Implementation of Ticagrelor Reduced Mortality in Routine Clinical Care: Evidence From a Natural Experiment Including 109 995 Patients With Myocardial Infarction in Sweden

“… 1 Observational studies on ticagrelor effectiveness in routine clinical care have since reported both no or negative effectiveness, 2 , 3 , 4 , 5 , 6 whereas others have supported the PLATO findings. 7 , 8 , 9 , 10 , 11 This creates uncertainty about current treatment guidelines that recommend ticagrelor treatment for patients with myocardial infarction.…”

The value of evaluating and implementing pharmaceuticals

“…189,190 Because ticagrelor treatment is generally initiated during hospitalisation, conditioning on surviving hospitalisation or having a ticagrelor prescription at or after discharge can introduce bias. Many previous observational studies on ticagrelor restricted study populations to those surviving hospitalisation, those treated with P2Y12-inhibitors, or both, [174][175][176]179,[181][182][183][184] which could explain part of the variation in the study results. Using prescription data after hospital discharge to estimate the effectiveness of treatments initiated during hospitalisation, bring to mind the analogy of looking for keys under the streetlight rather than where the keys were lost (the so called streetlight effect).…”

“…The impact of patient selection was investigated using inclusion and exclusion criteria from past observational studies [174][175][176]179,[182][183][184] : 1) patients surviving the index hospitalisation; 2) patients treated with a P2Y12-inhibitor; and 3) patients surviving hospitalisation and treated with a P2Y12inhibotor.…”

“…160,163 However, observational studies on ticagrelor use in clinical practice has produced varying and conflicting evidence on ticagrelor effectiveness. [175][176][177][178][179][181][182][183][184] Some studies have found positive effects from ticagrelor when used in clinical practice, including a study by Sahlén et al (2016) who analysed data collected as part of Swedish routine clinical practice. 174 Other studies have found zero and even negative effects of ticagrelor use in clinical practice, including a recent study by Szummer et al (2020) who found an increased risk of mortality associated with ticagrelor in patients above 80 years of age.…”